Medical Coding

Many have heard the conversations and read articles surrounding efforts to simplify E/M billing, coding, and documentation. Most of the larger proposed changes were officially postponed to 2021 which will give stakeholders time to influence the final policy. This announcement on November 1, 2018 coincided with the release of the 2019 Physician Fee Schedule (PFS) and Quality Payment Program (QPP) final rule. Providers (and coders alike) have long complained about…

We are frequently asked by clients and others in the industry about the number of diagnosis codes allowed on the electronic format as well as the paper forms when billing for services. This is especially true in risk adjustment where all current diagnoses are collected for financial forecasting purposes. Some try to use claim editing to capture these but ultimately a medical record review by an experience risk adjustment coding…

October was cybersecurity awareness month. While increased focus has been on this topic, many organizations are still left exposed and at serious risk. HIPAA laws do not apply overseas, thus there are zero protections for covered entities who choose to offshore services. It’s somewhat baffling that we can be concerned with the high cost of delivering healthcare, yet cannot allow a global marketplace for medications (one of the highest expenses),…

Epilepsy is a neurological disorder where patients suffer from seizures. These seizures are a result of excessive and abnormal cortical nerve cell activity in the brain. The cause of epilepsy in many patients may be unknown, but it can develop from brain injury, stroke, brain cancer, and drug or alcohol abuse. Seizures present differently based on the person’s age and the part of the brain involved. The most common seizures…

7th Characters were a new concept introduced in the first issue of ICD-10-CM in October of 2015. Various chapters of ICD-10-CM use a 7th character for different reasons. For example, in the eye chapter, the 7th character is used to identify the stage of glaucoma, in the OB section a 7th character is used to identify which fetus is involved, and in injuries, a 7th character is used to identify stage…

In October of 2015 there was new guidance on Excludes1 and the intention of the instructional note. Although the general ICD-10 instruction at that time was that an Excludes 1 note means you cannot code two conditions together, the National Center for Health Statistics posted an exception on their website. The NCHS is one of the 4 cooperating parties for ICD-10, and is responsible for posting the ICD-10 code book…

Over the years I have heard medical coders question the provider’s diagnosis. For example, someone might say, but how can you say the patient has CKD Stage III with that GFR lab? Or another might state, how can you say the patient has Protein Calorie Malnutrition, since the labs are all normal? There are many of these examples. We should always maintain a level of respect for providers and accept…

Under new guidance from ICD-10-CM, the term “with,” when used in the Alphabetical Index, Tabular, or instructional notes, was only used by ICD-10-CM authors when two conditions are normally associated with one another clinically. This means that the provider does not need to demonstrate a cause and effect relationship whenever the word “with” is found in ICD-10-CM as a descriptor in the Alphabetical Index, Tabular, or instructional notes. A. Conventions for…

New guidance is offered in the new ICD-10-CM for 2017 that is effective October 1, 2016 on laterality. There have been some questions on which side to assign codes when one side vs. another is being treated or addressed or repaired. These new guideline clarifications can be found below in blue: B. General Coding Guidelines 13. Laterality When a patient has a bilateral condition and each side is treated during…

There is an updated section of ICD-10-CM effective October 1, 2016 regarding the newly added NIH Stroke Scale (NIHSS) codes that have now been added this year to ICD-10-CM. The NIHSS can be used as a clinical stroke assessment tool to evaluate and document neurological status in acute stroke patients. The stroke scale is valid for predicting lesion size and can serve as a measure of stroke severity. The NIHSS has been…